Anticoagulation
Oral anticoagulation is a very effective treatment to prevent stroke in patients with atrial fibrillation. Management of anticoagulation in patients with stroke is a major clinical challenge and our research group is conducting different research projects to elucidate these clinical conundrums and provide evidence for clinically relevant questions.
One in six patients with stroke has a preceding anticoagulation therapy representing a major challenge among those patients potentially eligible for acute recanalization therapies (Meinel et al Ann Neurol 2021). Especially the number of patients on direct oral anticoagulants is rapidly increasing in recent years. Our research aims to elucidate the safety and efficacy of acute recanalization therapies in patients with preceding anticoagulation (Meinel et al STROKE 2020, Seiffge et al JNNP 2021, Seiffge et al JAMA Neurol 2021). We are currently leading national and international cooperations to answer questions on different patient selection approaches or the use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis.
We found that patients with atrial fibrillation who have a stroke despite taking anticoagulation are at increased risk of having further strokes (Seiffge et al Ann Neurol 2020). The diagnostic work-up and strategies for secondary prevention in this relevant high-risk patient population are currently poorly understood. In our research, we aim to disentangle the heterogeneous stroke pathophysiology in this subgroup. We are also comparing different secondary preventive options (addition of antiplatelet agents, switch of anticoagulation, left atrial appendage occlusion).
Whether patients who had a bleeding in the brain and who have atrial fibrillation should receive anticoagulation therapy is not well understood. Anticoagulation may significantly reduce the risk of ischemic stroke but it is unknown to what extend it might increases the risk of future haemorrhage. As national leader, we are coordinating an international, multi-center randomized controlled trial in Switzerland comparing oral anticoagulation using Edoxaban with standard therapy to provide high-quality evidence (ENRICH-AF; NCT03950076).
